1. Organization of Diabetes Care Alireza Esteghamati,MD Professor of Endocrinology and Metabolism Tehran University of Medical Sciences

2. The Chronic Care Model Improving Care for People Living with diabetes

3. Objectives n Define the problem in today’s health care systems n State 5 useful aims to keep in mind while seeking to improve care n Describe the development of the Chronic Care Model (CCM) n List the 6 components of the CCM

4. Key Points 1.Diabetes is a chronic disease that requires proactive, planned and population-based care 2.It takes a team. Diabetes care should involve a interdisciplinary team working within the chronic care model 3.Technology (telehealth, reminder systems, EMRs, etc.) can be used to improve care

5. A New Health system for the 21st Century n “The current care systems can not do the job.” n “Trying harder will not work.” n “Changing care systems will.”

6. Six Aims for Improving Health Systems Six Aims for Improving Health Systems n Safe: avoids injuries (no needless deaths, accidents, or injuries) n Effective: relies on latest scientific knowledge n Patient-centered: responsive to patient needs, values, and preferences n Timely: avoids delays n Efficient: avoids waste n Equitable: quality unrelated to personal characteristics ( everyone, everywhere can receive )

7. Implications for How to Change Practice n If the problem is the system, and not the individual “bad apples,” then the focus for practice improvement needs to shift. n Need to make the right thing to do the easy thing to do. 7

8. Usual Chronic Illness Care n 15 minute visit, poorly organized n Symptoms and lab results focus of discussion and exam, not preventive assessment n Patient’s attempts to discuss difficulties in living with the condition are discouraged

9. Usual Chronic Illness Care n Focus is on physician’s treatment, not patient’s role in management. n Treatment plan is limited to prescription refill and encouragement to make appointment if not feeling well n Visit ends with physician rifling through drawers looking for a pamphlet

10. Rationale for Population Based Care The current care delivery system was design for acute episodic care and does a poor job for chronic and preventive care. Until there is fundamental system change we will not do much better than the following: n Evidence based care given only 55% of time –(NEJM. 2003;348(26):2635-2645) n Blood sugar is controlled in only 37% of patients with diabetes –(JAMA. 2004:291(3):335-342) n Blood Pressure is controlled in only 35% of patients with hypertension –(Ann Intern Med. 2006;145(3):165-175) “ Every system is perfectly designed to get the results it gets”

11. Uninformed, Passive Patient Frustrating Problem-Centered Interactions Unprepared Practice Team Sub-optimal Functional and Clinical Outcomes Delivery System Design Reliance on short, unplanned visits Decision Support No agreement on good care; traditional referrals Clinical Information Systems Don’t know pts or what they need Self-Management Support No systematic approach; didactic in orientation Health System Resources and Policies No links with community agencies or resources Community Health Care Organization Leadership concerned about the bottom line Incentives favor more frequent, shorter visits No organized QI Usual Care Model

12. Sub Optimal Functional and Clinical Outcomes Unprepared Practice Team Uninformed, Passive Patient Frustrating Problem-Centered Interactions Usual Care Model

13. Reality: Guidelines are NOT Followed Care gap between diabetes management guidelines and real-life practice Organizational and evidence-based approach to treating chronic diseases Real Life Real Life Ideal Practice Ideal Practice

14. Chronic Care for a Chronic Disease Acute and reactive Proactive, planned, and population-based The Chronic Care Model

15. 15 To Change Outcomes Requires Fundamental Practice Change Reviews of interventions in several conditions show that effective practice changes are similar across conditions. Integrated changes with components directed at: Influencing physician behavior Influencing physician behavior Better use of non-physician team members Better use of non-physician team members Enhancements to information systems Enhancements to information systems Planned encounters Planned encounters Modern self-management support Modern self-management support Care management for high risk patients Care management for high risk patients

16. 16 System Change Concepts Why a Chronic Care Model? n Emphasis on physician, not system, behavior. n Characteristics of successful interventions weren’t being categorized usefully. n Commonalities across chronic conditions unappreciated.

17. Satisfaction Clinical Measures Cost External Review Measures Prepared, Proactive Practice Team Supportive, Integrated Community Productive Interactions Chronic Care Model Informed, Activated Patient Functional and Clinical Outcomes

18. Themes in the Chronic Care Model n Evidence-based –Valuing excellence (and evidence) over autonomy n Patient-centered –Each patient is the only patient n Population-based

19. Supportive, Integrated Community Productive Interactions Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Health System Resources and Policies Community Health Care Organization The Chronic Care Model Family Education & Self- Management Support Prepared, Proactive Practice Team Informed, Activated Patient

20. Elements of the Chronic Care Model 1. Delivery Systems Design: The Team 2. Self-Management Support 3. Decision Support 4. Clinical Information Systems 5. Community 6. Health Systems

21. Delivery System Design Clinical Information Systems Health System Health Care Organization Chronic Care Model Family Education & Self-Management Support Specific goals in organizations strategic/business plan Senior leader support Organization adopts performance improvement model Provider incentives support organizational goals Decision Support Community Resources and Policies

22. 22 Health Care Organization n Visibly support improvement at all levels, starting with senior leaders. n Promote effective improvement strategies aimed at comprehensive system change. n Encourage open and systematic handling of problems. n Provide incentives based on quality of care. n Develop agreements for care coordination.

23. Delivery System Design Clinical Information Systems Health System Resources and Policies Community Health Care Organization Chronic Care Model Family Education & Self- Management Support Evidence-based guidelines Provider education Referrals and specialist expertise Guidelines for patients Decision Support

24. 24 Decision Support n Embed evidence-based guidelines into daily clinical practice. n Integrate specialist expertise and primary care. n Use proven provider education methods. n Share guidelines and information with patients.

25. Decision Support Decision Support n Tools and techniques to improve patient care decisions n Flow sheets, electronic medical records (EMRs), care algorithms, accessible specialist support, education, etc. n Most helpful if available at point of care

26. Delivery System Design Clinical Information Systems Health System Community Resources and Policies Health Care Organization Chronic Care Model Emphasize patient/parent active role Collaborative care planning/problem solving Ongoing educational process Connections between family/patient and social support Standardized assessments of self-management Written management plan with goal setting Decision Support Family Education & Self-Management Support

27. Self-Management Support n Formerly known as Diabetes Education n Shift from didactic diabetes education to a patient-empowering motivational approach Problem-solving and goal-setting Problem-solving and goal-setting

28. 28 Self-Management Support n Emphasize the patient's central role. n Use effective self-management support strategies that include: assessmentgoal-setting action planning problem-solvingfollow-up. n Organize resources to provide support.

29. Delivery System Design Clinical Information Systems Health System Community Resources and Policies Health Care Organization Chronic Care Model Family Education & Self-Management Support Team roles and tasks (practice team, school, parents) Care based on accepted guidelines Primary care team assures continuity Regular follow-up care Decision Support

30. 30 Delivery System Design n Define roles and distribute tasks among team members. n Use planned interactions to support evidence-based care. n Provide clinical case management services for high risk patients. n Ensure regular follow-up. n Give care that patients understand and that fits their culture.

31. Delivery Systems Design: The Team n Expertise of nurses, dietitians, pharmacists, and psychological support n Team working with primary care physicians supported by specialists n Disease management model that uses patient education, coaching, treatment adjustment, monitoring, care co- ordination

32. You Your doctor Your nurse Your dietitian Your pharmacist YOU Optometrist or ophthalmologist Local diabetes education centre Foot care specialist Mental Health Professional Other people you know who have diabetes Physical activity specialist Dentist Heart specialist Kidney specialist Family and friends Your diabetes care team may include a …….

33. Delivery System Design Clinical Information Systems Health System Health Care Organization Chronic Care Model Family Education & Self-Management Support Registry to track clinically useful and timely information Registry reports/data for feedback Care reminders Assure timely planned follow-up Identification/proactive care of relevant patient subgroups Individual patient care planning Decision Support Community Resources and Policies

34. 34 Clinical Information Systems n Provide reminders for providers and patients. n Identify relevant patient subpopulations for proactive care. n Facilitate individual patient care planning. n Share information with providers and patients. n Monitor performance of team and system.

35. Delivery System Design Clinical Information Systems Health System Health Care Organization Chronic Care Model Family Education & Self-Management Support Partnerships Key school contact identified Input Educational services available Decision Support Community Resources and Policies

36. 36 Community Resources and Policies n Encourage patients to participate in effective programs. n Form partnerships with community organizations to support or develop programs. n Advocate for policies to improve care.

37. Assessment and tailoring Collaborative problem definition Evidence-based clinical management Goal-setting and problem-solving Shared care plan Active, sustained follow-up Community integration and support Prepared, Proactive Practice Team How Would I Recognize Good Care for People with Chronic Illness? Supportive, Integrated Community Informed, Activated Patient Productive Interactions Functional and Clinical Outcomes

38. 38 Evidence-based Clinical Change Concepts A Recipe for Improving Outcomes Learning Model System Change Concepts System change strategy

39. 39 Essential Element of Good Chronic Illness Care Informed, Activated Patient Productive Interactions Prepared Practice Team

40. 40 What characterizes an “informed, activated patient”? Informed, Activated Patient They have the motivation, information, skills, and confidence necessary to and confidence necessary to effectively make decisions about effectively make decisions about their health and manage it. their health and manage it.

41. Informed, Activated, Patient  Patient understands the disease process and realizes his/her role as the daily self-manager  Family and caregivers are engaged in the patient’s self- management  The provider is viewed as a guide on the side, not the sage on the stage!

42. 42 What characterizes a “prepared” practice team? Prepared Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care.

43. Prepared Practice Team Has the:  Patient information  Decision support  People  Equipment  Time To deliver:  Evidence-based clinical management  Self-management support

44. 44 Assessment of self-management skills and confidence as well as clinical status.Assessment of self-management skills and confidence as well as clinical status. Tailoring of clinical management by stepped protocol.Tailoring of clinical management by stepped protocol. Collaborative goal-setting and problem-solving resulting in a shared care plan.Collaborative goal-setting and problem-solving resulting in a shared care plan. Active, sustained follow-up.Active, sustained follow-up. Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?

45. 45 Features of Case Management n Regularly assess disease control, adherence, and self-management status. n Either adjust treatment or communicate need to primary care immediately. n Provide self-management support. n Provide more intense follow-up. n Provide navigation through the health care process.

46. 46 Advantages of a General System Change Model n Applicable to most preventive and chronic care issues. n Once system changes in place, accommodating new guideline or innovation much easier.

47. Self-Management Education

48. Self-Management Education (SME) A systematic intervention that involves active patient participation in self-monitoring and/or decision-making

49. Key Points 1.Diabetes self-management education (SME) improves health parameters 2.SME should teach behaviours as well as knowledge and technical/problem-solving skills 3.SME should be patient-centred, tailored to the individual, use a variety of teaching methods and be regularly reinforced

50. Knowledge is Power n Empowering patients through self- management education improves: – A1C – Quality of life – Weight loss – Cardiovascular fitness

51. Basic Knowledge and Skills n Monitoring health parameters (including SMBG]) n Healthy eating n Physical activity n Pharmacotherapy and medication adjustment n Hypo-/hyperglycemia prevention/management n Prevention and surveillance of complications n Problem identification and solving

52. Not Just Knowledge: Work on Behavior! n Cognitive-behavioral interventions improve self-management and metabolic outcomes n They may involve: – Cognitive re-structuring – Problem-solving – Cognitive-behavioural therapy (CBT) – Stress management – Goal setting – Relaxation

53. How should SME be delivered? Interdisciplinary team and/or peer-education Personal contact with healthcare workers Combination of group and individual sessions Combination of didactic and interactive

54. Diabetes Education… Improved! n Collaborative and interactive n Patient-centred and individualized n Knowledge and technical skills, but also problem-solving skills n Repeatedly reinforced n Educational, psychological, and behavioral interventions and a variety of teaching methods

55. Steps to Success Evaluate and support long-term self-management Implement a realistic plan for skills training Collaborate on decisions and goals for action Make informed consideration of self-care options Assess & identify personal self-care needs

56. Self-Management Support This section contains: n 5A’s Self-Management support forms n Goal Setting form n Patient education handouts

57. Using the 5 “A’s” With Diabetes n Assess n Advise n Agree n Assist n Arrange

58. Using the 5 “A’s” With Diabetes Assess: What does the patient know about diabetes. Are they ready to learn? What are their values and culture? n Advise: Prioritize an individual plan for your patient in partnership with them. n Agree: Start with goals patient has identified and assist them in creating ways to meet their goals.

59. Using the 5 “A’s” With Diabetes n Assist: Develop a long-term plan for the patients which is agreed upon by both patient and provider. Assist patient in identifying barriers to success. n Arrange: Continue to follow-up and assist patient

60. 5A’s Self Management Support Form Specific for Diabetes

61. 5A’s Self Management Support Form Generic for any condition

62. Patient Education Tools n Help patients prepare for, and know what to expect from, a diabetes visit

63. Diabetes Self Management Goal Setting Form

65. Patient Education Handout

72. The Chronic Care Model (CCM) Saves Lives The CCM improves: 1.A1C 2.LDL-C 3.Use of statins 4.Drug and hospital expenditures 5.Overall mortality